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OBJECTIVE—The purpose of this study was to evaluate the effectiveness of a temperature monitoring instrument to reduce the incidence of foot ulcers in individuals with diabetes who have a high risk for lower extremity complications.

RESEARCH DESIGN AND METHODS—In this physician-blinded, randomized, 15-month, multicenter trial, 173 subjects with a previous history of diabetic foot ulceration were assigned to standard therapy, structured foot examination, or enhanced therapy groups. Each group received therapeutic footwear, diabetic foot education, and regular foot care. Subjects in the structured foot examination group performed a structured foot inspection daily and recorded their findings in a logbook. If standard therapy or structured foot examinations identified any foot abnormalities, subjects were instructed to contact the study nurse immediately. Subjects in the enhanced therapy group used an infrared skin thermometer to measure temperatures on six foot sites each day. Temperature differences >4°F (>2.2°C) between left and right corresponding sites triggered patients to contact the study nurse and reduce activity until temperatures normalized.

The purpose of the study was to assess in patients with a diabetic foot infection (DFI), whether differences in skin temperature of the affected foot as compared to the corresponding site on the contralateral foot using dermal thermometry (DT) correlates with infection severity and clinical outcome. As part of the SIDESTEP DFI study, investigators took DT measurements at baseline and the discontinuation of intravenous therapy (DCIV) and performed a systematic evaluation of the infected limb to calculate a wound score. We compared the skin temperature differential between the limbs at the two assessments and determined the correlation between this value and surrogate markers of inflammation and the clinical response to treatment. Among patients enrolled in SIDESTEP, 332 were fully evaluable. The mean temperature differential between the limbs was 2.81 +/- 5.75 degrees F at baseline and 2.43 +/- 4.84 degrees F at DCIV (mean change: -0.37; 95% confidence interval (CI): -0.98, 0.23; P= 0.225). Skin temperature differential at baseline did not correlate with white blood cell count, level of C-reactive protein or erythrocyte sedimentation rate or the infection severity score (r= 0.058, 0.148, -0.002, 0.067, respectively). We observed no overall trend between surface temperature differential at baseline and clinical outcome at DCIV, but patients with a skin temperature differential of >/=10 degrees F at baseline had a significantly lower clinical response than those whose differential was <10 degrees F (81.4% versus 94.3%; difference 12.9%; 95% CI: 3.5, 27.3%, P= 0.007). While there was no overall relationship between skin temperature and poor clinical outcome, there may be a threshold effect in DT (<10 degrees F versus >10 degrees F) between the limbs at baseline that predicts outcome of therapy.

NEW YORK (Reuters Health) - Adding a daily check of foot temperature with an infrared skin thermometer to standard diabetic foot therapy can significantly reduce the recurrence of foot ulcers, doctors in Texas and Chicago report in the medical journal Diabetes Care.

Co-investigator Dr. Lawrence A. Lavery, at Texas A&M University Health Science Center in Temple, and his associates point out that elevated skin temperature is a sign of inflammation and tissue injury, but the signs may be too subtle to detect.

The team randomly assigned 173 diabetic patients between 18 and 80 years of age to one of three treatment groups for 15 months. One group received standard therapy, consisting of a foot evaluation every 8 weeks, therapeutic insoles and footwear, and an education program.

A second group received the same treatment, plus instructions to inspect the bottom of their feet with a mirror twice daily.

The enhanced therapy group received the same treatment as the second, but also used the TempTouch thermometer daily and were told to notify the study nurse if the temperature at the same site differed by more than 4 F.

About 30 percent of subjects in the first two groups developed a new foot ulcer, compared with only 8.5 percent in the third group. Ninety percent of the first two groups also had full-thickness ulcers by the time they noticed a problem.

"Once patients identify a hot spot, they are told to modify their activity and stay off their feet until the temperature normalizes," Lawson said, which is probably what reduced the ulcer rate.

Background: A study was conducted to compare the accuracy, reliability, and essential features of nine commercially available handheld infrared thermometers used to manage the neuropathic foot.

Methods: The thermometers were compared using two temperature-control sources simulating physiologic conditions found in a foot-care clinic. With each control source independently set, temperature difference ranges of 0 degrees , 2 degrees , 4 degrees , and 6 degrees C were randomly sampled and analyzed for each thermometer by two testers. The order of testing was randomly assigned for testers and instruments.

Results: There were differences in mean temperature change among thermometers (P < .001) and between testers (P = .0247). Differences in mean temperature change among instruments (<0.5 degrees C), although small, could affect interpretation of skin temperature if temperature comparisons are made using two different instruments. The difference in temperature change between testers (0.06 degrees C) was not large enough to affect decisions in clinical practice. Instrument response time, distance-to-spot ratio, sensor diameter, display resolution, emissivity, and cost were compared.

Conclusions: The low-cost, general-use infrared thermometers used in this study showed good accuracy, reliability, and performance and are appropriate for use in a foot-care clinic.

Purpose
To evaluate the effectiveness of home temperature monitoring to reduce the incidence of foot ulcers in high-risk patients with diabetes.

Methods
In this physician-blinded, 18-month randomized controlled trial, 225 subjects with diabetes at high risk for ulceration were assigned to standard therapy (Standard Therapy Group) or dermal thermometry (Dermal Thermometry Group) groups. Both groups received therapeutic footwear, diabetic foot education, regular foot care, and performed a structured foot inspection daily. Dermal Thermometry Group subjects used an infrared skin thermometer to measure temperatures on 6 foot sites twice daily. Temperature differences >4°F between left and right corresponding sites triggered patients to contact the study nurse and reduce activity until temperatures normalized.

Results
A total of 8.4% (n = 19) subjects ulcerated over the study period. Subjects were one third as likely to ulcerate in the Dermal Thermometry Group compared with the Standard Therapy Group (12.2% vs 4.7%, odds ratio 3.0, 95% confidence interval, 1.0 to 8.5, P = .038). Proportional hazards regression analysis suggested that thermometry intervention was associated with a significantly longer time to ulceration (P = .04), adjusted for elevated foot ulcer classification (International Working Group Risk Factor 3), age, and minority status. Patients that ulcerated had a temperature difference that was 4.8 times greater at the site of ulceration in the week before ulceration than did a random 7 consecutive-day sample of 50 other subjects that did not ulcerate (3.50 ± 1.0 vs 0.74 ± 0.05, P = .001).

Conclusions
High temperature gradients between feet may predict the onset of neuropathic ulceration and self-monitoring may reduce the risk of ulceration.

William Buchanan takes his temperature every morning, but he doesn't hold a thermometer under his tongue. He holds it to the bottom of his feet.

The 76-year-old retired right-of-way agent for the New York Telephone Company has Type II diabetes and has subsequently lost sensation in his feet. He uses the TempTouch to help prevent ulcers that could lead to amputation..

Two years ago, Buchanan, who lives in Queens, was shopping with his wife when he took a spill in a parking lot..

"I got up and walked to the car, no problem," he said. "The next morning I used 'the wand' and there was a big difference in readings between my right and left foot.".

An X-ray revealed that Buchanan had broken his left toe..

"If I didn't have that wand to check with, I would have walked around for a couple weeks without feeling it and I would have wound up with an infection," Buchanan said. "And then I would have had a big problem - off with the leg.".

Clinical trials, including one that will be published in December in the American Journal of Medicine, are proving that skin temperature monitoring significantly reduces foot ulcers in diabetics who suffer neuropathy - numbness in their extremities..

Dr. David Armstrong, director of the Scholl College Center for Lower Extremity Ambulatory Research (CLEAR) at Rosalind Franklin University of Medicine and Science and the James A. Lovell Federal Health Center in North Chicago, Ill., was principal investigator and lead author on the latest study using the infrared TempTouch..

Armstrong began using a thermometer to help prevent foot ulcers in his patients 15 years ago as a medical student and resident..

"I spent $700 and bought this fancy thermometer I put in my pocket," he said. "I would tell my patients 'You've got to buy one of these. I know it's a lot of money, but it will help keep your feet on.'".

Diabetics can now use the wand-like, gooseneck TempTouch before they begin their day's activities. A spike in temperature warns that an infection is brewing so they can stay off their feet until the threat of an ulcer subsides..

"A wound will heat up before the skin breaks down," said Armstrong, professor of surgery and associate dean at Rosalind Franklin's Scholl College of Podiatric Medicine. "You can detect infection by checking one foot compared to another foot, one toe compared to another toe.".

Problems with feet account for about one-third of all hospital admissions for people with diabetes, according to Armstrong who lectures around the world on treatment of the diabetic foot and ways to prevent amputations..

The latest clinical trial found that study participants who used the TempTouch were three times less likely to develop ulcers compared to those in the standard therapy group who were instructed on how to visually inspect their feet..

Armstrong insists many people with diabetes have trouble examining their feet and that only between 10 and 20 percent ask their doctor to do so during routine check-ups..

"Many can't reach their feet," Armstrong said. "Many have retinopathy - they can't see well. And the diabetic foot doesn't bother them. They have lost 'the gift' of pain.".

Ruben Zamorano, president of San Antonio-based Xilas Medical, which holds the patent for the TempTouch, said Armstrong and other podiatrists have been working with bio-medical engineers to develop "new weapons" to fight diabetic ulcers, which cost $14,000 per patient to treat in the first year..

"A doctor may heal an ulcer but people go right back into the same situation in the same shoes that caused the problem," Zamorano said. "The whole problem comes back to prevention.".

Xilas donated 5,000 foot thermometers to Texas Medicaid patients who at have a high rate of diabetes-related amputations. The company received a $1 million emerging technology grant from the state in 2006. It has also contracted with insurance companies in New York City and Tennessee..

Armstrong and other leading podiatrists hope "dermal thermometry" becomes a norm in treatment of the diabetic foot..

More people with diabetics will begin using hand-held devices like the TempTouch, which costs $150, as they become easier to use and cheaper to manufacture and as more insurers reimburse for them, said Dr. James Christina, director of scientific affairs for the American Podiatric Medical Association..

But while insurance companies pay lip service to preventive care, they are often reluctant to make the up-front investment..

"We still have challenges with getting insurance companies to pay for prevention visits to podiatrists in some cases," Christina said. "That's a big problem. Preventive care can be so cost effective. Studies show a whole-team approach to helping diabetics take care of their feet can help prevent ulcerations and amputations.".

Armstrong, who warned of the "silent tsunami of diabetic amputations" at the International Diabetic Foot Conference in Singapore last summer, warned that complications of diabetes is crippling people in their prime working years. He hopes companies that pay the premiums for employee health care will begin paying for prevention, even if insurers won't..

"Companies will save money by stopping these problems before this tsunami overtakes us," Armstrong said. "The wave is already cresting.".

The aim of this study was to evaluate foot temperature in type 2 diabetic patients with vs. without peripheral neuropathy. The study included 30 patients (group A: 16 men, mean age 63.23+/-7.02 years) with peripheral neuropathy and 30 patients (group B: 17 men, mean age 62.37+/-6.73 years) without peripheral neuropathy. Neuropathy was diagnosed by the Diabetic Neuropathy Index (DNI). Foot temperature was measured with a handheld infrared thermometer (KM 814, Kane-May, UK) on the mid-dorsal aspect of the foot (dorsal temperature) and on the plantar aspect of the foot at the level of the first metatarsal head (plantar temperature). Dorsal temperature was significantly higher in group A than in group B (right foot 32.89+/-1.02 degrees C vs. 31.2+/-1.07 degrees C, p<0.001). The same significant difference was observed for the plantar temperature (32.2+/-0.94 degrees C vs. 30.7+/-1.07 degrees C, p<0.001). In both groups, a significant positive correlation was observed between dorsal and plantar temperature (group A: r (s)=0.913, p<0.001; group B: r (s)=0.956, p<0.001). Finally, in group A, DNI score showed a significant positive correlation with dorsal temperature (r (s)=0.856, p<0.001), as well as plantar temperature (r (s)=0.859, p<0.001).

CONCLUSIONS: Foot temperature is significantly higher in type 2 diabetic patients with neuropathy as compared to those without neuropathy. In patients with neuropathy, a significant positive correlation is observed between foot temperature and clinical severity of neuropathy.

INTRODUCTION AND OBJECTIVES: Patients with underlying peripheral neuropathy are subject to changes in foot temperature. (1,2) Of the many forms of neuropathy that affect the lower extremity, the most notable are those types associated with diabetes. The aim of this study was to look for differences in temperatures between uncomplicated diabetic, diabetic neuropathic, and non-diabetic neuropathic feet.

METHODS: The feet of 75 subjects were divided into 3 groups: 1) normal (n=50 feet), 2) diabetic (n=50 feet), and 3) neuropathic (n=49 feet). The neuropathic group was further subdivided into diabetic neuropathies (n=20 feet) and non-diabetic neuropathies (n=29 feet). To properly assign subjects to groups, all participants underwent vibratory threshold testing with a biothesiometer. In addition, all diabetic subjects had added glycosylated hemoglobin (hemoglobin A1C) studies performed. Temperature measurements were recorded at nine distinct foot locations (six plantar and three dorsal). Data was statistically analyzed using the Kruskal-Wallis test.

RESULTS: For five of the plantar pedal sites tested, temperatures in the diabetic foot were significantly greater than those for the normal controls (p<0.05). At most sites, temperatures in the diabetic foot population tended to be higher than those in both diabetic and non-diabetic neuropathic feet, with the differences between the diabetic foot and non-diabetic neuropathic foot being statistically significant at one dorsal and five plantar sites. Patients in the non-diabetic neuropathic group were not stratified according to their specific neuropathic types.

CONCLUSIONS: Diabetic feet, with and without neuropathy, tend to be warmer than the feet of patients with other non-diabetic neuropathies. The finding of no statistical difference between non-neuropathic diabetic and neuropathic diabetic feet is unexpected in that a number of these patients were projected to have an autonomic system component. These null findings suggest the need to further investigate neuropathy solely determined by sensory testing versus tests for autonomic system involvement.

Prevention of serious diabetic foot complication like ulceration or infection is an important issue. As the development of thermal graphic technologies, foot temperature-guided avoidance therapy has been recommended. Doctors from Hospital National Dos de Mayo are studying on the risk of the diabetic foot passing from Grade 0 to Grade 1 in the Wagner Scale. This risk to develop ulcers is related to the temperature difference of corresponding area between left and right foot. Generally speaking, the diabetic foot with greater mean temperature difference has more potential to develop ulcers; especially, area whose temperature difference of more than 2.2°C is where doctors and patients must pay much attention to potential problems like ulceration or infection. A system in Visual Studio was developed taking the thermal images as input and producing image with absolute mean temperature difference of 7different regions or four plantar angiosomes as output. The program process contained essential medical image processing issues such as segmentation, location and regionalization, in which adapted algorithms were implemented. From a database of 85 patients provided only 60 were used due to the quality of acquisition.

Highlights
•Cadence affects rate of foot temperature change but not final foot temperatures.
•Foot temperatures are observed to plateau during prolonged walking.
•Foot temperature changes inversely correlated with initial temperature of the foot.
•This correlation is stronger in older participants than younger participants

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This study examined the relationship between (1) foot temperature in healthy individuals and walking cadence, (2) temperature change at different locations of the foot, and (3) temperature change and its relationship with vertical pressures exerted on the foot. Eighteen healthy adult volunteers (10 between 30-40 years − Age: 33.4 ± 2.4 years; 8 above 40 years − Age: 54.1 ± 7.7 years) were recruited. A custom-made insole with temperature sensors was placed directly onto the plantar surface of the foot and held in position using a sock. The foot was placed on a pressure sensor and the whole system placed in a canvas shoe. Participants visited the lab on three separate occasions when foot temperature and pressure data were recorded during walking on a treadmill at one of three cadences (80, 100, 120 steps/min). The plantar foot temperature increased during walking in both age groups 30-40 years: 4.62 ± 2.00 °C, >40 years: 5.49 ± 2.30 °C, with the rise inversely proportional to initial foot temperature (30-40 years: R2 = −0.669, >40 years: R2 = −0.816). Foot temperature changes were not different between the two age groups or the different foot locations and did not depend on vertical pressures. Walking cadence affected the rate of change of plantar foot temperature but not the final measured value and no association between temperature change and vertical pressure was found. These results provide baseline values for comparing foot temperature changes in pathological conditions which could inform understanding of pathophysiology and support development of evidence based healthcare guidelines for managing conditions such as diabetic foot ulceration (DFU).

Early identification of areas of inflammation may aid prevention of diabetic foot ulcers. A new bespoke thermal camera system has been developed to thermally image feet at risk. Hotspots (areas at least 2.2 °C hotter than the contralateral site) may indicate areas of inflammation prior to any apparent visual signs. This article describes the thermal pattern and symmetry of 103 healthy pairs of feet. 68% of participants were thermally symmetric at the 33 foot sites measured. 32% of participants had at least one hotspot, but hotspots overall only accounted for 5% of the measurements made. Refinements to the definition of hotspots are proposed when considering feet at risk of ulceration.

In this paper a description is given of the development, characterisation and first results of a thermal imaging device aimed at significantly reducing the incidence of diabetic foot ulceration (DFU). These devices will be used in three clinical centres and in two preliminary clinical trials. The first will be on healthy volunteers to set a robust baseline for the overall research aims and the second on >100 patients at high risk of DFU. In the second phase of the project the objective is to demonstrate significant reduction in the incidence of DFU through a comparison of the results of standard care of high risk feet with standard care plus thermal imaging.

Highlights
•Advances in the study of the thermal changes associated to the Diabetic through Infrared Thermography.
•Classification of thermal changes according to a difference of temperature regarding to the control pattern.
•Identification of the wide variety of thermal distributions in a DM group.

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One of the main complications caused by diabetes mellitus is the development of diabetic foot, which in turn, can lead to ulcerations. Because ulceration risks are linked to an increase in plantar temperatures, recent approaches analyze thermal changes. These approaches try to identify spatial patterns of temperature that could be characteristic of a diabetic group. However, this is a difficult task since thermal patterns have wide variations resulting on complex classification. Moreover, the measurement of contralateral plantar temperatures is important to determine whether there is an abnormal difference but, this only provides information when thermal changes are asymmetric and in absence of ulceration or amputation. Therefore, in this work is proposed a quantitative index for measuring the thermal change in the plantar region of participants diagnosed diabetes mellitus regards to a reliable reference (control) or regards to the contralateral foot (as usual). Also, a classification of the thermal changes based on a quantitative index is proposed. Such classification demonstrate the wide diversity of spatial distributions in the diabetic foot but also demonstrate that it is possible to identify common characteristics. An automatic process, based on the analysis of plantar angiosomes and image processing, is presented to quantify these thermal changes and to provide valuable information to the medical expert.

Foot ulcers account for 15% of comorbidities associated with diabetes. Presently, no device allows the status of foot ulcers to be continuously monitored when patients are not hospitalized. In this study, we describe a temperature and a pH sensor capable of monitoring diabetic foot and venous leg ulcers developed in the frame of the seventh framework program European Union project SWAN-iCare (smart wearable and autonomous negative pressure device for wound monitoring and therapy). Temperature is measured by exploiting the variations in the electrical resistance of a nanocomposite consisting of multiwalled carbon nanotubes and poly(styrene-b-(ethylene-co-butylene)-b-styrene). The pH sensor used a graphene oxide (GO) layer that changes its electrical potential when pH changes. The temperature sensor has a sensitivity of ~85 Ω/°C in the range 25°C–50°C and a high repeatability (maximum standard deviation of 0.1% over seven repeated measurements). For a GO concentration of 4 mg/mL, the pH sensor has a sensitivity of ~42 mV/pH and high linearity (R2=0.99).

Prevention of serious diabetic foot complication like ulceration or infection is an important issue. As the development of thermal graphic technologies, foot temperature-guided avoidance therapy has been recommended. Doctors from Hospital National Dos de Mayo are studying on the risk of the diabetic foot passing from Grade 0 to Grade 1 in the Wagner Scale. This risk to develop ulcers is related to the temperature difference of corresponding area between left and right foot. Generally speaking, the diabetic foot with greater mean temperature difference has more potential to develop ulcers; especially, area whose temperature difference of more than 2.2°C is where doctors and patients must pay much attention to potential problems like ulceration or infection. A system in Visual Studio was developed taking the thermal images as input and producing image with absolute mean temperature difference of 7different regions or four plantar angiosomes as output. The program process contained essential medical image processing issues such as segmentation, location and regionalization, in which adapted algorithms were implemented. From a database of 85 patients provided only 60 were used due to the quality of acquisition.

BACKGROUND:
Nowadays, the whole world is being concerned with a major health problem, which is diabetes. A very common symptom of diabetes is the diabetic foot ulcer (DFU). The early detection of such foot complications can protect diabetic patients from any dangerous stages that develop later and may require foot amputation. This work aims at building a mobile thermal imaging system that can be used as an indicator for possible developing ulcers.
METHODS:
The proposed system consists of a thermal camera connected to a Samsung smart phone, which is used to acquire thermal images. This thermal imaging system has a simulated temperature gradient of more than 2.2 °C, which represents the temperature difference (in the literature) than can indicate a possible development of ulcers. The acquired images are processed and segmented using basic image processing techniques. The analysis and interpretation is conducted using two techniques: Otsu thresholding technique and Point-to-Point mean difference technique.
RESULTS:
The proposed system was implemented under MATLAB Mobile platform and thermal images were analyzed and interpreted. Four testing images (feet images) were used to test this procedure; one image with any temperature variation to the feet, and three images with skin temperature increased to more than 2.2 °C introduced at different locations. With the two techniques applied during the analysis and interpretation stage, the system was successful in identifying the location of the temperature increase.
CONCLUSION:
This work successfully implemented a mobile thermal imaging system that includes an automated method to identify possible ulcers in diabetic patients. This may give diabetic patients the ability for a frequent self-check of possible ulcers. Although this work was implemented in simulated conditions, it provides the necessary feasibility to be further developed and tested in a clinical environment.

Home monitoring of skin temperature is effective to prevent diabetic foot ulceration. We explored the validity of various definitions for the >2·2°C left-to-right threshold used as a warning signal for impending ulceration. Twenty patients with diabetes and peripheral neuropathy monitored their skin temperature with an infrared thermometer at the plantar hallux, metatarsal heads, midfoot and heel four times a day for 6 consecutive days. Environmental temperature and walking activity were monitored and associated with foot temperature. The average temperature difference between feet was 0·65°C. At single locations, a left-to-right temperature difference of >2·2°C was found 245 times (8·5% of measurements). Confirmation of these above-threshold readings on the following day was found seven times (0·3%). Corrected for individual left-to-right mean foot temperature differences, this reduced to four (0·2%). No ulcers developed in the week after monitoring. Left-to-right foot temperature differences were not significantly correlated with walking activity, environmental temperature or time of day. The >2·2°C left-to-right foot temperature threshold for impending ulceration is not valid as single measurement, but validity improves to acceptable levels when an above-threshold temperature difference is confirmed the following day and further improves with individual correction. The threshold is independent of time of day, environmental temperature and walking activity.

Background: One of the complications of the diabetes mellitus is the amputation of the lower limbs. This complication may be developed after an insidious ulcer, that may be raised by the peripheral neuropathy or the ischaemic limb, and that the ulcer get infected. That is, to develop an ulcer, in the diabetic patient, three factors should be taken into the account, the autonomic nervous system, the blood supply and the inmune system. Methods: In this work, the thermogram is used to identify regions on the plantar skin with blood supply deficiencies and the behaviour of the thermoregulation process. Within the thermogram of the plantar skin, it can be identify local regions with low and high temperatures that corresponds to ischemic or inflammatory process on that part of the skin. Results: The findings within the 186 thermograms of diabetic patients, obtained from three hospitals and from INAOE facilities, showed, first, the thermograms of the plantar skin of two diabetic patients, acquired in two different times show that the temperature distribution and the average temperatures, vary slightly for a period of weeks. Second, the thermograms of two patients, who both developed insidious ulcers which evolved favourable, demonstrated the importance of the immune system and the drug therapy. These patients are, one who has a Charcot foot, and in the second one, the patient had loss the sensibility of the feet. Finally, the thermograms of two patients, showing abrupt temperature change within small regions in the plantar skin, are discussed. Conclusion: A diabetic patient, with an asymmetric thermogram, as physiological interpretation of the thermoregulation, may indicate a decrease of the blood supply, which may be corroborated by vascular ultrasound. The regions of abrupt temperature change, cold or hot spots, may correspond to ischaemic or inflammatory processes.

Highlights
•Characterization of diabetic foot is proposed using Infrared thermography.
•Nonlinear features extracted from thermograms.
•Ranked features are subjected to SVM classifier.
•Maximum accuracy of 89.39% using only five features.

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Diabetic foot is a major complication of diabetes mellitus (DM). The blood circulation to the foot decreases due to DM and hence, the temperature reduces in the plantar foot. Thermography is a non-invasive imaging method employed to view the thermal patterns using infrared (IR) camera. It allows qualitative and visual documentation of temperature fluctuation in vascular tissues. But it is difficult to diagnose these temperature changes manually. Thus, computer assisted diagnosis (CAD) system may help to accurately detect diabetic foot to prevent traumatic outcomes such as ulcerations and lower extremity amputation. In this study, plantar foot thermograms of 33 healthy persons and 33 individuals with type 2 diabetes are taken. These foot images are decomposed using discrete wavelet transform (DWT) and higher order spectra (HOS) techniques. Various texture and entropy features are extracted from the decomposed images. These combined (DWT + HOS) features are ranked using t-values and classified using support vector machine (SVM) classifier. Our proposed methodology achieved maximum accuracy of 89.39%, sensitivity of 81.81% and specificity of 96.97% using only five features. The performance of the proposed thermography-based CAD system can help the clinicians to take second opinion on their diagnosis of diabetic foot.

AIM:
To evaluate the potential of thermography as an assessment tool for the detection of foot complications by understanding the variations in temperature that occur in type 2 diabetes mellitus (DM).

METHODS:
Participants were categorized according to a medical examination, ankle brachial index, doppler waveform analysis, and 10-gram monofilament testing into five groups: healthy adult, DM with no complications, DM with peripheral neuropathy, DM with neuroischaemia, and DM with peripheral arterial disease (PAD) groups. Thermographic imaging of the toes and forefeet was performed.

RESULTS:
43 neuroischaemic feet, 41 neuropathic feet, 58 PAD feet, 21 DM feet without complications, and 126 healthy feet were analyzed. The temperatures of the feet and toes were significantly higher in the complications group when compared to the healthy adult and DM healthy groups. The higher the temperatures of the foot in DM, the higher the probability that it is affected by neuropathy, neuroischaemia, or PAD.

CONCLUSIONS:
Significant differences in mean temperatures exist between participants who were healthy and those with DM with no known complications when compared to participants with neuroischaemia, neuropathy, or PAD. As foot temperature rises, so does the probability of the presence of complications of neuropathy, neuroischaemia, or peripheral arterial disease.

Highlights
•Characterization of diabetic foot with and without neuropathy is proposed using Infrared thermography.
•Nonlinear features extracted from thermograms.
•Reduced and ranked features are subjected to kNN classifier.
•Maximum accuracy of 93.16% using only four LSDA features.

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Diabetic foot is the most common problem among diabetic patients, mainly due to peripheral vascular and neuropathy induced capillary perfusion changes. These pathogenic factors cause superficial temperature changes that can be qualitatively and visually documented using infrared thermography (IRT). Hence, IRT can potentially be used to evaluate the diabetic foot. However, it is tedious to manually interpret these subtle temperature variations by inspecting the feet thermal image. Therefore, an automated system to detect diabetic foot with and without neuropathy is proposed. In this study, 51 healthy individuals and 66 diabetic patients (33 with and 33 without neuropathy) are considered. The segmented plantar foot thermograms are decomposed into coefficients using double density-dual tree-complex wavelet transform (DD-DT-CWT). Several entropy and texture features are extracted from the decomposed images of left, right and bilateral foot. These features are reduced using various dimensionality reduction techniques and subsequently ranked using F-values. The ranked features are fed individually into the different classifiers one by one. The developed system yielded 93.16% accuracy, 90.91% sensitivity and 98.04% specificity using only four locality sensitive discriminant analysis (LSDA) features obtained from bilateral foot thermal images with k-nearest neighbour (kNN) classifier. This automated diabetic foot detection system can be introduced in polyclinics and hospitals to clinically support the clinicians to confirm their manual diabetic foot diagnosis.

This study aimed to determine whether thermal imaging can detect temperature differences between healthy feet, nonulcerated neuroischemic feet, and neuroischemic feet with toe ulcers in patients with type 2 diabetes mellitus (T2DM). Participants were prospectively divided into 3 groups: T2DM without foot problems; a healthy, nonulcerated neuroischemic group, and an ulcerated neuroischemic group. Thermal images of the feet were obtained with automated segmentation of regions of interest. Thermographic images from 43 neuroischemic feet, 21 healthy feet, and 12 neuroischemic feet with active ulcer in one of the toes were analyzed. There was a significant difference in toe temperatures between the 3 groups (P = .001), that is, nonulcerated neuroischemic (n = 181; mean temperature = 27.7°C [±2.16 SD]) versus neuroischemic ulcerated (n = 12; mean temperature = 28.7°C [±3.23 SD]), and healthy T2DM group (n = 104; mean temperature = 24.9°C [±5.04 SD]). A post hoc analysis showed a significant difference in toe temperatures between neuroischemic nonulcerated and healthy T2DM groups (P = .001), neuroischemic ulcerated and healthy groups (P = .001). However, no significant differences in toe temperatures were identified between the ulcerated neuroischemic and nonulcerated neuroischemic groups (P = .626). There were no significant differences between the ulcerated toes (n = 12) and the nonulcerated toes (n = 57) of the same foot in the ulcerated neuroischemic group (P = .331). Toe temperatures were significantly higher in neuroischemic feet with or without ulceration compared with healthy feet in patients with T2DM. There were no significant differences in temperatures of ulcerated toes and the nonulcerated toes of the same foot, implying that all the toes of the same foot could potentially be at risk of developing complications, which can be potentially detected by infrared thermography.

Comparative thermal map of the foot between patients with and without diabetes through the use of infrared thermography.
Astasio-Picado Á et alEnferm Clin. 2019 Jan 7

OBJECTIVE:
The objective of the study is to analyze, through the use of infrared thermography, the variability of foot temperature in diabetic and non-diabetic patients by segmenting the sole of the foot in four study areas.

METHOD:
A cross-sectional study was proposed on a sample of 479 subjects divided into two groups, a group of people with diabetes and a group of people without diabetes. The diabetes group comprised a total of 277 people, with an average age of 63.41 years, [138 men (49.8%) and 139 women (50.2%)], and the group without diabetes comprised 202 individuals, with an average age of 61.92 years, [99 men (49%) and 103 women (51%)]. The images were taken using the FLIR E60bx® camera. IBM SPSS Statistics 22 software was used for the statistical data analysis.

RESULTS:
The results show temperature variability in the different areas of study of the sole of the foot bilaterally and there were also differences according to whether the patient belonged to the diabetic or the non-diabetic group.

CONCLUSIONS:
The use of infrared thermography in the evaluation of the foot at risk could demonstrate the variability of temperature by study area, which could be useful in the area of healthcare for the diagnosis and prevention of injuries to compromised areas of the foot.

BACKGROUND:
Diabetes mellitus is a public health problem worldwide. The diabetic foot has a degenerate vascular structure, and its patients present neurological problems, which require the earliest possible identification.

INTRODUCTION:
The objective of the research was to use infrared thermography to analyze the temperature difference of the feet of users with diabetes mellitus with neuropathy, vasculopathy, neurovascular disease, or none of them, segmenting the sole of the foot in four areas for the study.

METHOD:
A type of descriptive, cross-sectional and observational study was developed in a group of 277 patients with diabetic pathology (138 men and 139 women), with an average age of 63.41 ± 17.69 years and a body mass index of 29.08 ± 5.86, delimited in four groups: 22 (7.94%) with neuropathy, 32 (11.55%) with vasculopathy, 83 (29.96%) with neurovasculopathy and 140 (50.54%) without previous pathology. Thus, almost half of the sample (49.46%) presented some type of complication (neuropathic, vasculopathic or both). The photographic images were made with an infrared camera model FLIR E60bx®. The data obtained were analyzed using the IBM SPSS Statistics 22 statistical program.

RESULT:
There were lower temperatures under the 1st metatarsal head, the 5th metatarsal head, the heel, and pulp of the big toe of both left and right feet of the patients in the neuropathy, vasculopathy, and neurovasculopathy groups relative to the group with neither pathology.

CONCLUSION:
Infrared thermography can be useful in assessing the foot at risk to reveal the variability of temperature according to the study area, which may be useful for medical judgment and the predisposition to identify lesions in compromised regions of the foot

BACKGROUNDiabetes mellitus is a public health problem worldwide. The diabetic foot has a degenerate vascular structure, and its patients present neurological problems, which require the earliest possible identification. INTRODUCTION:The objective of the research was to use infrared thermography to analyze the temperature difference of the feet of users with diabetes mellitus with neuropathy, vasculopathy, neurovascular disease, or none of them, segmenting the sole of the foot in four areas for the study. METHOD:A type of descriptive, cross-sectional and observational study was developed in a group of 277 patients with diabetic pathology (138 men and 139 women), with an average age of 63.41 ± 17.69 years and a body mass index of 29.08 ± 5.86, delimited in four groups: 22 (7.94%) with neuropathy, 32 (11.55%) with vasculopathy, 83 (29.96%) with neurovasculopathy and 140 (50.54%) without previous pathology. Thus, almost half of the sample (49.46%) presented some type of complication (neuropathic, vasculopathic or both). The photographic images were made with an infrared camera model FLIR E60bx®. The data obtained were analyzed using the IBM SPSS Statistics 22 statistical program. RESULT:There were lower temperatures under the 1st metatarsal head, the 5th metatarsal head, the heel, and pulp of the big toe of both left and right feet of the patients in the neuropathy, vasculopathy, and neurovasculopathy groups relative to the group with neither pathology. CONCLUSION:Infrared thermography can be useful in assessing the foot at risk to reveal the variability of temperature according to the study area, which may be useful for medical judgment and the predisposition to identify lesions in compromised regions of the foot.

One of the diseases that could affect diabetic patients is the diabetic foot problem. Unnoticed
minor injuries and subsequent infection can lead to ischemic ulceration, and may end in a foot
amputation. Preliminary studies have shown that there is a positive relationship between increased
skin temperature and the pre–ulceration phase. Hence, we have carried out a review on wearables,
medical devices, and sensors used specifically for collecting vital data. In particular, we are interested
in the measure of the foot–temperature. Since there is a large amount of this type of medical wearables,
we will focus on those used to measure temperature and developed in Spain.

BACKGROUND:
Prior research shows increased foot temperatures are predictive of diabetes-related foot complications. Our aim was to describe normative skin foot temperatures for individuals with diabetic peripheral neuropathy to better inform new technologies. We also explored for potential risk factors which correlate with changes in foot temperatures.

METHODS:
We conducted a retrospective chart review of adult patients >18 years of age with diabetes mellitus and clinically diagnosed diabetic peripheral neuropathy with pedal digital thermometry performed between 2009 and 2018. A total of 58 patients met these criteria. Univariate modeling was based on covariates that may affect foot temperature including age, peripheral arterial disease, toe pressure, seasonality of measurement, smoking pack-years, caffeine use, insulin use, and calcium channel blocker use.

CONCLUSION:
Normative foot temperatures in neuropathic patients were found to be inversely associated with seasonality at the toe and metatarsal level. Smoking and pack-year history demonstrate modest correlation previously unseen in temperature analyses and warrant further exploration. Normative temperatures in neuropathic patients can better inform new technologies for the prevention of diabetic foot ulcer and Charcot neuroarthropathy.

Between visit variability of thermal imaging of feet in people attending podiatric clinics with diabetic neuropathy at high risk of developing foot ulcers.
Macdonald A et alPhysiol Meas. 2019 Jul 30.

Objective People with diabetic neuropathy who have previously ulcerated are at high risk of re-ulceration. They should regularly attend podiatry clinics for surveillance and routine protective podiatric treatment. It has been suggested that inflammation prior to skin breakdown shows up as a hotspot on a thermal image even in the absence of clinical signs. The aim of this study is to quantify inter-patient and intra-patient thermal variations presented by diabetic feet at high risk of ulceration. &amp;#13; Approach Whole foot and spot temperatures were recorded for 96 patients who attended two successive podiatry appointments without ulceration 28 [28, 31] days apart, median [interquartile range]. This was a part of a longer study into whether thermal imaging in clinic can reduce the rate of re-ulceration. &amp;#13; Main results The variation in spot temperature right/left differences for single patients between visits was comparable to the variation observed between patients (0.8 [0.3,1.5] °C compared with 0.9 [0.4,1.7] °C). Similarly, whole foot temperature variation for a single patient between visits was comparable to the variation observed between patients (0.6 [0.2,1.1] °C compared with 0.8 [0.2,1.3] °C). &amp;#13; Significance Thresholds which depend on thermal differences from visit to visit are unlikely to have sufficient specificity to effectively target treatment designed to prevent the development of foot ulcers.

METHODS:
People with diabetes (n=110), neuropathy and history of ≥1 foot ulcer participated in a single-blind multicentre clinical trial. Feet were imaged with a novel thermal imaging device (Diabetic Foot Ulcer Prevention System). Participants were randomized to intervention (active thermography + standard foot care) or control (blinded thermography + standard foot care) and were followed up monthly until ulcer recurrence or for 12 months. Foot thermograms of participants from the intervention group were assessed for hot spots (areas with temperature ≥2.2°C higher than the corresponding contralateral site) and acted upon as per local standards.

CONCLUSIONS:
Monthly intervention with thermal imaging did not result in a significant reduction in ulcer recurrence rate or increased ulcer-free survival in this cohort at high risk of foot ulcers. This trial has, however, informed the design of a refined study with longer follow-up and group stratification, further aiming to assess the efficacy of thermography to reduce ulcer recurrence.

OBJECTIVE:
To investigate the dependability of a thermal gadget connecting to a smartphone. Comparing the exact temperature of damaged tissue with adjacent parts of the limb and to evaluate the changes in thermal conductivity of hard-to-heal wounds in patients with a diabetic foot ulcer (DFU).

METHODS:
Potential candidates were divided into three groups and selected from different hospitals in Tehran. Group 1 contained patients with inflammation, Group 2 were patients with vascular complications, and Group 3 were patients who were managing to control their glucose levels to an acceptable level, according to their medical records (i.e. 'healthy cases'). All thermal images were taken without any external stimulus, in room temperature conditions after 15 minutes' rest. All medical records were confirmed by therapeutic supervisors. Moreover, the tissue conditions in patients were considered in the computational part of the study. The temperatures of the ulcer and adjacent tissues were observed and compared. The collected data were used in a suggested model for human tissues and the method of calculation in this study was trial and error. In this study, patients in Group 2 were considered in the computational section of the study.

RESULTS:
Temperature difference between the wounds and adjacent tissues for the big toe in three patients in Group 2 was 2.2ºC for the healthier candidate and almost 6.9ºC in the worst case. By comparing the thermal conductivity of normal and damaged tissues, a significant reduction in thermal conductivity was observed for the candidate with the worst status of big toe by about 84.3%. For the other two candidates in this category, it was almost 68.86% and 20.47%.

CONCLUSION:
The variation in thermal conductivity represents the change in tissue properties. Thermal conductivity can be applied for early DFU detection. This data may allow introduction of the smartphone thermometer as an authentic and alternative apparatus that is beneficial in diabetic clinics as well as self-assessment by patients. Moreover, due to the decrease in thermal conductivity, this study suggests using intelligent thermal sheets in vulnerable parts of the diabetic foot.

METHODS:
We completed a planned analysis of existing data from a recent study in 129 participants with a previously-healed diabetic foot ulcer. We considered four cohorts: all participants, participants with partial foot amputation, participants with a recent wound, and participants without partial foot amputation and without a recent wound. We reported the prediction specificity, lead time, and annualized alert burden in each cohort at maximum sensitivity. We assessed the two potentially challenging cohorts for non-inferior accuracy relative to the control cohort using Delong's method.

RESULTS:
We report non-inferior predictive accuracy in each of the two potentially-challenging cohorts relative to the control cohort (⍺ < 0.05). The alert lead time was similar across these cohorts, ranging from 33 to 42 days.

CONCLUSIONS:
Once-daily foot temperature monitoring is no less accurate for predicting foot ulceration in those with recent wounds and partial foot amputations than in those without these complications. These results support expanded practice of once-daily foot temperature monitoring, which may result in improved patient outcomes and reduced healthcare resource utilization.

According to the World Health Organization (WHO), Diabetes Mellitus (DM) is one of the most prevalent diseases in the world. It is also associated with a high mortality index. Diabetic foot is one of its main complications, and it comprises the development of plantar ulcers that could result in an amputation. Several works report that thermography is useful to detect changes in the plantar temperature, which could give rise to a higher risk of ulceration. However, the plantar temperature distribution does not follow a particular pattern in diabetic patients, thereby making it difficult to measure the changes. Thus, there is an interest in improving the success of the analysis and classification methods that help to detect abnormal changes in the plantar temperature. All this leads to the use of computer-aided systems, such as those involved in artificial intelligence (AI), which operate with highly complex data structures. This paper compares machine learning-based techniques with Deep Learning (DL) structures. We tested common structures in the mode of transfer learning, including AlexNet and GoogleNet. Moreover, we designed a new DL-structure, which is trained from scratch and is able to reach higher values in terms of accuracy and other quality measures. The main goal of this work is to analyze the use of AI and DL for the classification of diabetic foot thermograms, highlighting their advantages and limitations. To the best of our knowledge, this is the first proposal of DL networks applied to the classification of diabetic foot thermograms. The experiments are conducted over thermograms of DM and control groups. After that, a multi-level classification is performed based on a previously reported thermal change index. The high accuracy obtained shows the usefulness of AI and DL as auxiliary tools to aid during the medical diagnosis.

Introduction: Diabetic foot ulcers (DFUs) are devastating, common, and costly. The mortality of veterans following a DFU is sobering with ulceration recognized as a significant marker of disease severity. Given the dramatic impact of diabetic foot complications to the veteran and the US health care system, the US Department of Veterans Affairs (VA) has long recognized the importance of preventive care for those at risk. Telemedicine has been suggested as a modality to reach veterans at high risk of chronic wound formation.

Observations: The purpose of this review is to: (1) present the evidence supporting once-daily remote temperature monitoring (RTM), a telemedicine approach critical to improving both veteran access to care and diabetic foot outcomes; (2) summarize a 2017 study published by VA providers who have advanced clinical understanding of RTM; (3) present previously unpublished data from this study comparing high-risk VA and non-VA cohorts, highlighting the opportunity for additional focus on DFU prevention within the VA; and (4) report on recent VA use of a RTM technology based on this research, emphasizing lessons learned and best practices.

Conclusions: There is a significant opportunity to shift diabetic foot care from treatment to prevention, improving veteran outcomes and reducing resource utilization. RTM is an evidence-based, recommended, but underused telemedicine solution that can catalyze this needed paradigm shift.

Aim: The aim of this study was to perform an up-to-date systematic review and meta-analysis of randomized controlled trials (RCTs) examining the efficacy of home foot temperature monitoring, patient education and offloading footwear in reducing the incidence of diabetes-related foot ulcers.

Methods: A literature search was performed using MEDLINE, PubMed, CINAHL, Scopus and Cochrane databases to identify relevant original studies. Meta-analyses were performed using intention-to-treat principals for worst (main analysis) and best (sub-analysis) case scenarios. Leave-one-out sensitivity analyses were used to assess the consistency of findings.

Conclusion: This meta-analysis suggests that offloading footwear is effective in reducing the incidence of diabetes-related foot ulcers. Home foot temperature monitoring also appears beneficial but larger trials are needed

Diabetic foot is one of the main complications of diabetes in the whole world. Its symptoms and problems get worse over time and may include numbness, tingling, loss of sensation and pain in the limbs. Our goal is to develop a smart sock able to control some measures such us temperature or humidity and tells the patient whether ulcers may appear. As one of the first steps, we want to: (i) study the best sensors to take the temperature in the feet, (ii) give important reasons about the amount of regions of interest (ROis) necessary to perform a good screening in the diabetic foot, and for optimizing the study, eliminating areas that offer redundant results. In this work, first, we analyze the different sensors in the scientific literature. As a consequence, we find that it could be complicated to collocate many sensors at each sock. Therefore, in the second part, we derive a statistical analysis about which are the best 4-5 points where sensors should be placed.